legal impications in nursing

Legal Impications in Nursing

DocumentationDocumentation

What do nurses document(What do we ldquoput in writingrdquo)

bull Patient informationbull Nursing care

deliveredbull Outcomes of carebull Policies amp

proceduresbull Administrative

records

How do nurses document

bull Electronicallybull Paperpenbull Dictationtranscriptionbull Some combination of

above

Where do nurses document

bull ldquoNurses notesrdquo or anursing care sectionversus an integrated

record- Patients with cancer

mayhave multiple records

Why do nurses document

bull Provides an account of the care delivered

bull Promotes continuity of care

bull Reduces redundancy in care delivered

bull Supports chargesbilling

bull May be your best defense---or your worst

bull enemymdashin the event of legal action

Why do patients sue

bull To obtain compensation for perceived

harminjurybull To obtain informationbull To retaliate vent anger or frustrationbull To ldquoprevent this from happening to anyone elserdquobull (Family) To advocate on behalf of injured or

deceased relative

Elements needed to support allegations

of negligence

bull Duty exists

bull Duty was breached

bull Breach in care caused or contributed to patient harm

What kinds of documentation may bereviewed in a malpractice case

bull 1048708 Patientrsquos medical record

bull 1048708 ldquoOff the recordrdquo documentation

bull 1048708 Policies and procedures

bull 1048708 Personnel and administrative records

bull 1048708 Photographs

bull 1048708 Other

Legal considerations

bull MDs RNs and

pharmacists are

independently licensedbull The multidisciplinary

ldquoteamrdquo often falls apart

when litigation is

initiated

bull Patient is 6 feet 3

inches tall

___________ inches

Patient is 6rsquo 3rdquo tall1048708 Nurse erroneously converts to 63rdquoinstead of 75rdquo and records 63rdquo in themedical record1048708 Miscalculated BSA = 2011048708 Correct BSA = 221048708 Patient under-dosed 111048708 Patient has testicular cancer and wins ajury verdict of $500000

Treatment plan (progress notes)

Chemotherapy orders document that aldquodouble checkrdquo was done by the nurses

Double-checks (Joint Commission 2007)1048708 One person performs a review or calculation

twice1048708 Least reliable double-check method

Second type of double-check1048708 Second person looks at calculation to

confirm ldquo(ldquoeyeballs itrdquo)

Third type of double-check1048708 Second person recalculates after

watchingfirst calculation or knowing calculation

Fourth type of double-check1048708 Second person recalculates without

having seenthe first personrsquos calculation (independent

doublecheck)Most reliable

Realities of documentation

bull ldquoIf it wasnrsquot charted itwasnrsquot donerdquobull ldquoThe palest ink isbetter than the bestmemoryrdquobull Considered by someauthors to be the 6thright of medicationadministration

bull ldquoIf you cannot acquire the habit of documentation

one way or other you

had better give up being

a nurse for it is not your

calling however kind you may berdquo

Barriers to timely and complete documentation

bull ldquonot enough timerdquobull ldquokeep getting interrupted

or distractedrdquobull ldquohard to keep all the

patients straightrdquobull ldquonot humanly possible to

chart the way we were

taught in nursing schoolrdquo

Accurate documentation is dependent upon

bull A thorough physical

assessmentbull Use of standardized

measures (eg pain scale)bull Promptly recording

findings

and interventionsbull Chemotherapy

Chemotherapy documentation

bull Complete information about agents administeredbull Evidence of double checking (and what you aredouble checkingmdashBSA Labs Drugdose)bull Peripheral administration site device attemptsblood return site condition upon completion PortCVC administration device sizegauge ofnon-coring needle blood return skin assessmentbull Monitoring blood return frequencybull Patient teaching vesicant precautions generalchemotherapy information

Flowsheets amp ElectronicDocumentation

bull Beware of the process of ldquocheck check checkrdquo or ldquoclick click clickrdquo

bull Why is the patient herebull What has been donebull What is the patientrsquos responsebull Look for redundanciesbull 1048708Ensure individualization of entries

bull ldquoWhat is of most

concern to you

right now

Commonly confused words

bull Proximal and distalbull Abduct and adductbull Contralateral and

ipsilateral

Abbreviations

bull WNLbull LOCbull Joint Commission introduced ldquodo not userdquo list ofbull abbreviations in 2004bull U and IU spell out unit and international unit qd qodetc spell outbull No trailing zero (eg 20 mg)bull Use leading zero (eg 08 mg)bull MS and MS04 spell out morphine and

magnesium

Ambiguous amp literal wording

bull Incident report ldquoPatient started falling and states that mother tried to catch her but hit head on bathroom doorrdquo

bull P amp P ldquoCheck for blood returnrdquo

Best practice

bull Tell patientsfamilies

what yoursquore doing and

what yoursquore findingbull Reinforce informationbull Document truthfully

Now itrsquos up to you

bull Proactively examine your clinical practices

bull Take a look at your policies and procedures

bull Streamline your documentation tools or systems

bull Share what yoursquove learned with your colleagues

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What do nurses document(What do we ldquoput in writingrdquo)

bull Patient informationbull Nursing care

deliveredbull Outcomes of carebull Policies amp

proceduresbull Administrative

records



above












Why do patients sue



deceased relative


of negligence

bull Duty exists









bull 1048708 Other


bull MDs RNs and

pharmacists are



when litigation is

initiated


inches tall

___________ inches






























findings








concern to you

right now



ipsilateral

Abbreviations


magnesium




Best practice









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above












Why do patients sue



deceased relative


of negligence

bull Duty exists









bull 1048708 Other


bull MDs RNs and

pharmacists are



when litigation is

initiated


inches tall

___________ inches






























findings








concern to you

right now



ipsilateral

Abbreviations


magnesium




Best practice









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Why do patients sue



deceased relative


of negligence

bull Duty exists









bull 1048708 Other


bull MDs RNs and

pharmacists are



when litigation is

initiated


inches tall

___________ inches






























findings








concern to you

right now



ipsilateral

Abbreviations


magnesium




Best practice









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of negligence

bull Duty exists









bull 1048708 Other


bull MDs RNs and

pharmacists are



when litigation is

initiated


inches tall

___________ inches






























findings








concern to you

right now



ipsilateral

Abbreviations


magnesium




Best practice









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bull 1048708 Other


bull MDs RNs and

pharmacists are



when litigation is

initiated


inches tall

___________ inches






























findings








concern to you

right now



ipsilateral

Abbreviations


magnesium




Best practice









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bull MDs RNs and

pharmacists are



when litigation is

initiated


inches tall

___________ inches






























findings








concern to you

right now



ipsilateral

Abbreviations


magnesium




Best practice









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inches tall

___________ inches






























findings








concern to you

right now



ipsilateral

Abbreviations


magnesium




Best practice









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findings








concern to you

right now



ipsilateral

Abbreviations


magnesium




Best practice









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concern to you

right now



ipsilateral

Abbreviations


magnesium




Best practice









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ipsilateral

Abbreviations


magnesium




Best practice









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Abbreviations


magnesium




Best practice









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Best practice









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legal impications in nursing

Documents